Cases reported "Diarrhea, Infantile"

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11/26. Cyclosporin-responsive enteropathy and protracted diarrhea.

    We describe a child born to unrelated parents who developed severe protracted secretory type diarrhea associated with subtotal villus atrophy and intestinal inflammation at the age of 19 months. No infectious, metabolic, or anatomical basis for this condition was identified and the child required total parenteral nutrition for a period of 18 months despite trials of special enteral formulas, steroids, and anti-inflammatory agents. This refractory "enteropathy" responded dramatically to the introduction of cyclosporin, with cessation of the secretory diarrhea, recovery from the enteropathy, and cessation of parenteral nutrition. The symptoms relapsed when cyclosporin was briefly discontinued and improved following reintroduction of this drug. This experience suggests a role for immune factors in the pathogenesis of the enteropathy in this case and that a trial of cyclosporin is worthy of consideration in similar cases.
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12/26. Travellers' diarrhoea among children returning to the United Kingdom from visits abroad.

    Between January 1984 and March 1986, 10 children aged between 7 and 56 months were admitted to Queen Elizabeth Hospital for Children in london with chronic travellers' diarrhoea, after visiting the Indian subcontinent, france or morocco. All the children were born in the United Kingdom and had been in good health before their journey abroad. On return to england most of these children were malnourished and two of them (twins) had a post-infective, tropical malabsorption-like syndrome. There was a high incidence of positive stool cultures and, on small intestinal biopsy, histological abnormalities were present in six. Children from the United Kingdom travelling abroad are at risk of developing severe travellers' diarrhoea, with serious consequences to their health and nutrition. There is a need for intensive parental education before travelling and this could be achieved through community health workers.
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13/26. From aralu to ORS: Sinhalese perceptions of digestion, diarrhea, and dehydration.

    This paper explores popular Sinhalese perceptions of diarrheal diseases and related health care behavior. Also addressed are cultural interpretations of dehydration and perceptions of oral rehydration solution (ORS). The social marketing of ORS is considered. It is suggested that the marketing of ORS be more closely linked to education programs which promote appropriate conceptualization of dehydration. The need to more closely integrate nutrition education and diarrheal management programs is discussed.
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14/26. aluminum hydroxide in the symptomatic treatment of infants with chronic diarrhea.

    Two neonates with milk intolerance and two older infants, one with acute gastroenteritis and the other with prolonged malnutrition, developed chronic diarrhea. Despite bowel rest, total parenteral nutrition, and alterations in the protein and carbohydrate content of the milk preparations used, every attempt to feed them resulted in diarrhea. All four patients were given aluminum hydroxide because of its bile salt-binding activity and its tendency to cause constipation. Coincident with its administration the diarrhea stopped and the enteral feedings were successfully reinstituted. The only complication seen was the development of constipation in two of the infants; this responded to lowering of the dose of the aluminum hydroxide.
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15/26. Pneumococcal meningitis following parenteral alimentation in infants.

    Three young infants with protracted diarrhea and malnutrition were successfully treated by means of intravenous nutrition, which included infusions of fat emulsion (Intralipid) and of fresh frozen plasma. Three to five weeks after termination of intravenous feeding, and after full recovery, they developed pneumococcal septicemia and meningitis. One infant died, and postmortem examination showed diffuse deposition of "intravenous fat pigment" in hepatocytes and in reticuloendothelial cells. In the two infants who recovered, follow-up studies did not disclose any primary derangement of immunologic function. We propose that the infused fat may have caused a temporary depression of immunologic defense mechanisms, predisposing these infants to the pneumococcal infection; the delay in onset of the infection might be attributed to a short-lasting protective effect of fresh frozen plasma which was included in the intravenous feeding regimen.
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16/26. Communicating hydrocephalus following total parenteral nutrition.

    Communicating hydrocephalus secondary to cerebral venous outflow obstruction has been reported in a few patients several months following removal of a TPN catheter. We report the case of an infant who developed this sequal 4 mo after the catheter was removed. We illustrate the techniques used to delineate the type of hydrocephalus. A lumbo-peritoneal shunt was performed to alleviate the condition.
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17/26. The effect of continuous enteral feeding on cholic acid kinetics in a child.

    Continuous enteral feeding is utilized for nutritional support and specific therapy for several pediatric diseases, including protracted infantile diarrhea. Its effects on the enterohepatic circulation of bile acids were studied in a boy during continuous intragastric feeding of a high fat diet at age 42 months and after recovery while on bolus feedings at age 51 months. cholic acid kinetics measured by the isotopic dilution technique using cholic-COOH-14C acid and meal stimulated intraluminal bile acid concentrations were measured. cholic acid pool size was unaltered (1294 mg/m(2)) during continuous feeding compared to 999 mg/m(2) during bolus feeds and 1072 plus or minus 243 mg/m(2) (mean plus or minus SE) in nine control children. However, the cholic acid fractional turnover rate was increased 3-fold (0.912 days(-1)) during continuous feeds compared to 0.309 days(-1) during bolus feeding and 0.365 plus or minus 0.163 in controls. Similarly, synthesis rate was increased 3-4 fold during continuous feeds (1180 mg/m(2)/day) compared to controls (363 plus or minus 193 mg/m(2)/day) and the patient during bolus feeding (309 mg/m(2)/day). The intraluminal bile salt concentration was apparently reduced both during treatment (3.86 mM) and when bolus fed (3.85 mM) but were significantly different from controls (7.12 plus or minus 1.74 mM). During continuous enteral feeding with a high fat diet, effective homeostatic mechanisms in the enterohepatic circulation of bile salts ensured intraluminal bile salt concentrations adequate for normal fat solubilization and, consequently, normal fat absorption.
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18/26. biotin-responsive in vivo carboxylase deficiency in two siblings with secretory diarrhea receiving total parenteral nutrition.

    Two siblings with a congenital syndrome of secretory diarrhea and seizures developed progressive skin rash, alopecia, and mucocutaneous candidiasis while receiving biotin-free total parenteral nutrition. Abnormally low urinary biotin excretion was associated with these clinical findings, but the serum concentration of biotin was within the normal range. There was also increased urinary excretion of lactic acid, 3-hydroxyisovaleric acid, 3-hydroxypropionic acid, and 3-methylcrotonylglycine. The younger of the two children subsequently died with severe metabolic acidosis. In the oder sibling, intravenous treatment with biotin (200 micrograms/day) resulted in resolution of the organic aciduria. A larger dose (10 mg/day) appeared to be required for rapid improvement in the skin lesions. These cases suggest that clinically significant biotin deficiency can occur in patients with chronic diarrhea receiving biotin-free total parenteral nutrition.
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19/26. salmonella gastroenteritis in the first three months of life. A review of management and complications.

    Salmonellosis in older children and adults is usually a self-limited disease, but the risk of complications in infants is not well-defined. We performed a retrospective review of 52 patients. 90 days of age or less, seen at the St. Louis Children's Hospital between 1975 and 1981 with stool cultures positive for salmonella. Sixteen were 30 days old or less (neonates), 21 were 31- 60 days of age, and 15 were 61-90 days old. Among patients in whom blood cultures were done initially, bacteremia was most frequent in neonates: 5/11 (45%), compared to 2/18 (11%) in older infants. All seven infants presenting with bacteremia received 10 or more days of antibiotic therapy: yet complications (osteomyelitis, fatal meningitis or chronic diarrhea) developed in three of five neonates and one of two older infants. Complications also developed in seven of 22 patients who initially had negative blood cultures, including two infants in whom sepsis later developed and two infants who required intravenous hyperalimentation because of chronic diarrhea and malnutrition. The group of 23 patients who did not have blood cultures all did well. Salmonellosis is not necessarily a self-limited infection in young infants. Even in the absence of bacteremia, clinicans would appear to be justified in using antimicrobial therapy in infants 3 months of age or les with salmonella gastroenteritis, particularly neonates of older infants with symptoms of dysentery or failure to thrive.
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20/26. Intractable diarrhea of infancy due to intestinal coccidiosis.

    Intestinal coccidiosis in a 6-mo-old infant terminated fatally after 30 wk of continuous total parenteral nutrition, and proved refractory to treatment with antibiotics, hydrocortisone, and antimetabolic agents. Intestinal biopsies obtained at laparotomy revealed flattened mucosa infiltrated with coccidia at various stages of the parasites' life cycle. The course was characterized by severe diarrhea due to a cholera-like hypersecretion of intraluminal fluid. This case suggests that intestinal coccidiosis may be included among the small number of conditions responsible for authentic "intractable diarrhea of infancy."
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